PULMONARY EMBOLISM

HOW TO PREVENT AND SOLVE

EVIT RUSPIONO
INTRODUCTION

DIAGNOSIS

PROGNOSTIC ASSESSMENT

ACUTE PHASE TREATMENT

DURATION OF ANTICOAGULATION

CHRONIC THROMBOEMBOLIC PULMONARY HT

SPECIFIC TREATMENT
 PULMONARY EMBOLISM (PE)
A blockage of the lung's main artery / one of its
branches by a substance
that has traveled from elsewhere in the body
through the bloodstream (embolism).

Results from deep vein thrombosis (DVT) (commonly a

blood clot in a leg)
that breaks off and migrates to the lung, a process
termed venous thromboembolism (VTE).
 WHY CARE ?
1 of the big three cardiovascular killers, along with MI & stroke.

Case fatality rate 15 %, exceeds MI mortality rate.

Acute PE is the most serious clinical presentation of VTE.

The first presentation may be sudden death.

Over 317.000 death were related to VTE in 6 European countries
(2004). Of these cases, 34% with sudden fatal PE, 59% were deaths
from PE that remained undiagnosed during life.
 PREDISPOSING FACTORS
Strong Risk fators Moderate Risk fators Weak Risk fators
Fracture of lower limb Arthroscopic knee surgery Bed rest > 3 days

Hospitalization for HF / AF / Auto immune diseases DM

Atrial Flutter (within previous Blood transfusion HT
3 months)
Central Venous Lines Immobility due to sitting (e.g
Hip / knee replacement
prolonged car or air travel)
Chemotherapy
Major trauma Increasing age
Congestive heart / respiratory failure
MI (within previous 3 months) Laparoscopic surgery (e.g
Erythropoiesis stimulating agents cholecystectomy)
Previous VTE
Hormone replacement therapy Obesity
Spinal cord injury In vitro fertilization Pregnancy
Infection Varicose veins
Inflammatory bowel disease
Cancer (highest risk in metastatic disease)
Oral contraceptive therapy
Paralytic stroke
Post partum period
Thrombophilia
PATOPHYSIOLOGY
KEY FACTORS CONTRIBUTING TO HEMODYNAMIC COLLAPSE
IN ACUTE PULMONARY EMBOLY
INITIAL RISK STRATIFICATION OF ACUTE PE
 HOW TO DIAGNOSE ?

CLINCAL Pleuritic chest

CHARACTERISTIC
Dyspnea Cough
pain

Substernal
Fever Hemoptysis Syncope
chest pain

Signs of DVT
Unilateral leg Unilateral
pain extremity
swelling
CLINICAL PREDICTION RULES FOR PE WELLS RULE
CLINICAL PREDICTION RULES FOR PE REVISED GENEVA SCORE
Confirmed PE

A probability of PE high enough to indicate the need

for PE-specific treatment

Excluded PE

A probability of PE low enough to justify withholding

PE-specific treatment with an acceptably low risk

2014 ESC Guideline on Diagnosis & Management of Acute Pulmonary Embolism

 Suspected PE with shock or hypotension

CT angiography immediately available

No Yes

Echocardiography

RV overload

CT angiography
available & CT angiography
No Yes patient stabilized

No other test available / Positive Negative

patient stabilized

Search for other causes PE specific treatment: Search for other causes
Of hemodynamic instability Primary reperfusion Of hemodynamic instability

2014 ESC Guideline on Diagnosis & Management of Acute Pulmonary Embolism

 Suspected PE without shock or hypotension

Assess clinical probability of PE

Clinical judgement / prediction rule

Low / Intermediate clinical probability High clinical probability

Or PE likely Or PE likely

D - dimer

Negative Positive

CT angiography CT angiography

No PE PE confirmed No PE PE confirmed

No treatment
No treatment Treatment or investigation further
Treatment

2014 ESC Guideline on Diagnosis & Management of Acute Pulmonary Embolism

RECOMMENDATION
FOR DIAGNOSIS

2014 ESC Guideline on Diagnosis & Management of Acute Pulmonary Embolism

 VALIDATED DIAGNOSTIC CRITERIA FOR DIAGNOSING PE
IN PATIENTS WITHOUT SHOCK / HYPOTENSION ACCORDING TO CLINICAL PROBABILITY

2014 ESC Guideline on Diagnosis & Management of Acute Pulmonary Embolism

 SIMPLIFIED PULMONARY EMBOLISM SEVERITY INDEX (PESI)
Parameter Simplified PESI Version
Age 1 point (if age > 80 years)
Cancer 1 point
Chronic heart failure 1 point
Chronic pulmonary disease
Pulse rate 110 bpm 1 point
SBP < 100 mmHg 1 point
Arterial oxyhaemoglobin saturation 1 point
Risk strata
0 points = 30 day mortality risk1.0%
1 point(s) = 30 day mortality risk 10.9%

2014 ESC Guideline on Diagnosis & Management of Acute Pulmonary Embolism

CLASSIFICATION OF ACUTE PE BASED ON EARLY MORTALITY RISK

2014 ESC Guideline on Diagnosis & Management of Acute Pulmonary Embolism

 HOW TO SOLVE ?

Haemodynamic & respiratory support

Anticoagulation
Parenteral anticoagulation
Vitamin K antagonists
New oral anticoagulants
Thrombolytic treatment

Surgical embolectomy

Venous filters
 Clinical Suspicion of PE

Shock/hypotension

Diagnostic algorithm Diagnostic algorithm

Assess clinical risk

(PESI / sPESI)

Intermediate risk

RV function (echo / CT)

Lab testing

High risk Intermediate - high risk Intermediate - low risk Low risk

Primary A/C; monitoring; Hospitalization; Consider early

Consider rescue
Reperfusion reperfusion
A/C Discarge & home
treatment, if feasible
RECOMMENDATION FOR ACUTE PHASE TREATMENT

PE without shock / hypotension (intermediate or low risk)

PE with: Combination
Anticoagulation shock / hypotension
of parenteral(high risk)with VKA
treatment

2014 ESC Guideline on Diagnosis & Management of Acute Pulmonary Embolism

RECOMMENDATION FOR ACUTE PHASE REPERFUSION TREATMENT

2014 ESC Guideline on Diagnosis & Management of Acute Pulmonary Embolism

Adjustment of UFH dosage based on the aPTT

Approved thrombolytic regimens for PE

Contraindications to thrombolytic therapy

 TAKE HOME MESSAGES

1. Diagnosis
Clinical probability is the basis of all diagnostic strategies for PE.
Exclusion of PE using : Plasma D-dimer, CT angiography, V/Q scan.
Confirmation of PE using : Chest CT angiogram showing at least segmental PE,
High probability V/Q scan, CUS showing proximal DVT

2. Prognostic assessment
Unstable patients with shock or hypotension should immediately be identified
as high-risk patients.
Normotensive in PESI Class III / sPESI 1 constitute intermediate risk grup.
RV dysfunction & elevated cardiac markers classified into intermediate high
risk grup
 TAKE HOME MESSAGES

3. Acute phase treatment

Primary reperfusion treatment is the treatment of choise for patients with high
risk PE.
Without hemodynamic compromise, LMWH / fondaparinux is the initial
treatment of choice.
Systemic thrombolysis is not routinely recommended as primary treatment for
patients with intermediate high risk PE.
Percutaneous catheter directed treatment / surgical pulmonary embolectomy :
Alternative rescue procedures for intermediate high risk PE.
NOACs are non inferior than the standard anticoagulation regimen
 TAKE HOME MESSAGES

4. Duration of anticoagulation
For patients with unprovoked PE, oral anticoagulation is recommended for at
least 3 months.
In treatment of VTE, NOACs are both effective (in terms of prevention of
symptomatic or fatal VTE recurrence) and safe (particularly in terms of major
bleeding), probably safer than standard VKA regimens.
In patients who refuse to take or are unable to tolerate any form of oral
anticoagulants, aspirin may be considered for secondary VTE prophylaxis.